A growing body of evidence and expert reviews suggests that we should be altering our administration regimes of beta-lactam and carbapenams to accommodate an altered volume of distribution (or RRT) status of the critically ill patient in order to more effectively reach the inhibitory concentrations of drug required to kill susceptible pathogens.

Don't forget you can catch the full trials at pubmed.gov and enter the PMID within the infographic.

PDF included at bottom of page for a clearer graphic (incl. 811 references!)
Fullscreen of the graphic below: here.

Dr. Sergey Motov (USA Emergency Medicine) & Dr. David Lyness (UK ICM/Anaesthetics)UPDATE - NOVEMBER 2018
​
Taken from Dr Motov's work on a CERTA regime.
This is published in conjunction with the CERTA concept explanation here. We can all provide superior analgesia by using medication and techniques other than just opioid medications.This is NOT a definitive list and in all cases, local policies and protocols should be followed. Check your local formularies.
This is NOT a prescribing guideline - it is for EDUCATIONAL information ONLY.

We do not dispute the role of opioids in many spheres of practice, including emergency medicine, ICU and anaesthetics; rather we wish to highlight the pandemic of high opioid and opiate use. There are many medications available to reduce the amount of opioids used.​You may find, when considering your analgesia regimes that opioids are not always the best options for emergency pain issues.We would advocate the use of nerve blocks in the first instance to control acute pain, when feasible.

DO NOT mix NSAID drugs - ie) don't give two together

Caution with using NSAIDs where surgery could be imminent.

Caution masking escalating pain that could indicate a surgical emergency

Caution with the abuse potential of some drugs such as lyrica/pregabalin

When practical, we would suggest Physiotherapy, TENS and other non-pharmacological methods

Make sure you know the contraindications for NSAID use & consider a PPI when prescribing them

With respect to alternatives listed for non-radicular back pain, it has been brought to our attention that a new study was presented in 2017 which showed that "diazepam has no benefit when added to naproxen vs placebo" in acute low back pain. See here.

This is a difficult document to see online - so I have included a fullscreen version here and the A3 printable PDF below.

PLEASE let me know if you see any errors and I will try to fix them ASAP.
HD Fullscreen of the infographs are at the bottom
PDF at bottom of page

I preface this infographic with the caveat that it is an exercise in discussion only, not an exhaustive or conclusive analysis of all systematic reviews within this time period. I have done my best to accurately analyse the trawled data - please do get in touch if you have any suggestions on improvements. I have no conflicts of interest and am not involved in any systematic reviews or trials with any organisation.

1. It's a teaching & learning tool, rather than a document where people actually sit down and fill it in2. It is intended to provide a structure/framework for thought processes around referrals to HDU/ICU

RATIONALES

As a specialty, I feel we are working harder to demonstrate appropriate responses to colleagues who seek our help and expertise. We also have an educational obligation, like the rest of you, to ensure that all relevant staff outside intensive care understand the thought processes surrounding the referral process.This can lead to better decisions by the whole team.

Checklists are common in anaesthesia and intensive care medicine. Our daily reviews of ICU patients (usually) are done by proforma; either written or electronic, to ensure key but easily overlooked bits of information are not left out. This is why I have chosen to create an educational resource that includes a 'checklist' approach with key considerations. It is not meant to patronise anyone. In the same way that ICU assessment/review proformas, used by consultant team-members, do not feel undermining. This aims to reduce error and improve safety.

Quite often, most of the elements on the documents are already done - but sometimes this is over a longer period of time with frequent back-and-forwards from senior to junior staff. By having an 'aide-memoire', the whole team could realistically ensure that many appropriate key and utilisable pieces of information are available in an expedited fashion. Many of the less-considered blood tests and investigations often get left until quite late in the referral and transfer process. Being able to start specific treatments in a timely fashion is better for patients.This aims to speed up the time to results being available.

A general resource for ICU referral considerations, is likely to reduce some of the stress in sometimes particularly fraught scenarios. Anecdotally, it is sometimes nice to have something that can focus your thoughts on a patient who more often than not, is incredibly complex.This aims to reduce stress and error in the referral process.

The importance of 'baseline functional assessment' cannot be overstated. Discussions with patients, colleagues and family can provide excellent insight into the functional limitations of patients, which may change the entire course of a referral.This aims to provoke discussion about realistic goals of ICU intervention.

This resource could be considered as being more beneficial to junior members of a team, and is in no way intended to teach 'veterans' how to suck eggs; but there should be something in it for everyone.This aims to provide a source of education that is potentially useful to all members of staff.

I have also made a nursing section that is integral to this document. Ward nurses provide the cornerstone of care and assessment to all sick patients and are nearly always the first port of call when a patient is deteriorating. A lecturer in nursing contacted me to ask that I make 'SBAR' (Situation, Background, Assessment and Recommendation) a key recommendation when discussing patients with colleagues.This aims to be an educational tool for nursing staff and students.

The global aim of this educational resource is to add to patient safety, reduce delays, minimise errors and promote a shared mental model of approach to the assessment of the critically ill.

WHAT THIS IS RESOURCE IS NOTThese documents are NOT guidelines or policies and have not been ratified/tested for clinical use.

These documents do not replace the need for:Seeking help immediately, if required
Clinical judgement and assessment
Discussing patient's with the patient's consultant (on-call)

'Referral algorithms' are a tricky business - which is why, this is not one - it's a learning resource, and not a clinical guideline or mandate. Documents and checklists should not prevent you from seeking skilled help early. The documents do suggest things you should be mindful of, in sick patients.

It is impossible to predict every eventuality - but many of these principles are ubiquitous to all referrals.

With thanks given to Dr. Jonny Wilkinson, Dr. Adrian Wong and Dr Segun Olusanya for their thoughts on this project, as well as to everyone who has already commented on Twitter.

Hover over the infograph below and you will see four slides of content you can peruse through.

PAGE ONE = An assessment of the patient's current condition, history and baseline

PAGE TWO = A broader consideration of basic tests

PAGE THREE = Key advice about general considerations in the critically ill

Here are some of the more interesting ones (mostly SR's) that sprang up over January 2018...

As always, these are to provoke discussion on twitter, rather than me or anyone else giving a definitive 'what do I think' on them. Head on over to the websites mentioned at the bottom of the infographic to see some excellent commentaries on other trials. Particularly www.thebottomline.org.uk

ADRENAL was launched at Critical Care Reviews in January 2018.
The rest that I have featured are systematic reviews.

Many thanks to all publishers, authors and researchers who endeavour to make their research free to access to the #FOAMed community.

It has certainly been a year of great #FOAMed for Critical Care and Anaesthetics...

In this short round-up of the Propofological year - we look at 10 topics of the year as well as projects I've been involved in, infographics we've created, podcasts, YouTube channel, #IFAD2017 and perhaps talk about some of what's to come in 2018.

1. SEPSIS 3.000000 - is still here...! Seems to be at every conference I attend!

2. POCUS - a fan favourite in the community. More people picking up the probe this year! A great deal of excellent resources popping up all over the place. Critical Care Northampton have excellent resources for POCUS-mad practitioners!

3. Fluid Management (less seems to be more?) - #IFAD2017 hammered home the need to REALLY think about fluid prescriptions in the critically ill. They highlighted sepsis is primarily a condition of vasoplegia where patients may also require fluid... it's not solely a problem of hypovolaemia. This probably ties in with our own experiences with IV fluids where there is, in many conditions, a resus phase, plateau and de-resuscitation phase. Such is the scale of the problem we came together and developed a protocol for fluid prescription focusing on the four D's... IV FLUID PROTOCOL

4. Renal Issues - bicarb/NAC protection is a bit of a myth when it comes to IV contrast. We may not have been blown away by the outcome of the PRESERVE trial, but it certainly helped to confirm suspicions.

5. A fascinating sepsis trial in Zambia increase focus onto current sepsis management in developing countries. Not generally applicable to developed countries population, but still enormous amount of food for thought and a lot of interesting data. Many patients were HIV positive, and the inotrope used was dopamine (cheap and widely available). Lots of questions remain to be answered (and asked) about why this protocol performed so badly vs standard care.

6. Presentation skills at conferences still leave a lot to be desired. At nearly every conference, I could imagine Mr Ross Fisher's despairing face, wailing at the presenter for reading out endless slides of boring data. A key piece of advice would be that people do not come for you to read them your data, they come to hear your opinion on your data. Provide articles in advance, provide data in advance and deliver a TALK to your audience. More about P3 presentation skills here by Ross Fisher...

7. Opioid alternative regimes are still interesting a vast number of practitioners out there. I published a list of alternatives with Dr. Sergey Motov in 2016, which vent viral at this year's @Core_EM via Dr. Anand Swaminathan. You can see it here along with the 'concept' here. Perhaps one of the things I would like to mention about this piece of work is that they are SUGGESTIONS for opioid alternatives. We would hate to be labelled as zealots when it comes to an anti-opioid stance - it would be foolish not to recognise the important role of opioids as an analgesic - particularly when I use them in anaesthetics every day! But it would be equally foolish to approach all pain-types with opioids. There is an evidence base that Dr Motov has ploughed into and referenced for this resource, and it does require an update in 2018 (given new evidence about diazepam in back pain etc.) - which will be coming up in January! There is also plenty of room for multi-modal analgesia within many specialties.

8. A little more about #IFAD2017. Many thanks to the wonderful Prof. Manu Malbrain for inviting me to form part of the core faculty at IFAD this year. He is an inspirational man and a phenomenal host, who really understands the power of social media in intensive care medicine. Unapologetic of his technological stance when it comes to a fairly traditional conference, he has revolutionised this event and made more than 24 million impressions via Twitter, world-wide as well as boosting real-term participation of the conference by up to 1000 extra via webinars and online interaction. The material that was curated by the social media team is still being used at this moment by people across Twitter and the internet. I look forward to joining him again for the next event.

9. Born out of the IFAD social media team was a group of us who wanted to move forward together in critical care #FOAMed and develop a new and exciting project which will bring us a new and exciting style of critical care conference in the UK.... more on this in 2018.

10. Discussions ebb and flow in Twitterland, some of them more tiresome that others. A desire to move on from discussions over DL vs VL and Sux vs Roc is growing and hopefully will continue to flourish into 2018. Having spoken about this in some of our podcasts, I think a good proverb may be, for many, many, many aspects of medicine; "There are many ways to skin a cat". Often, it's good to disagree - but - sometimes it's better to just move on and discuss something else... at least for a while.

Below are some great resources to highlight some of the efforts that have dominated my own year in educational material:

The Propofology/QuickMedic YouTube channel continues to grow with free content. Check out one of our first videos in 2017 here... many more on the channel!

The summary that I have made of the top #FOAMed trials for ICU is available in infogram form, here.

www.CriticalCareNorthampton.com by Dr. Jonny Wilkinson continues to provide excellent blog posts, trawling the net for excellent critical care articles and projects. We have collaborated extensively this year with #IFAD2017 and in other projects to bring some excellent material to the fore. We hope you have enjoyed this as much as we have. Jonny has my particular thanks this year as being a wonderful contributor to Propofology projects as well as getting us involved in as many different aspects of #FOAMed as practically possible. Check out some of our stuff:

The references for all of these trials can be found in the various months here or via a quick google search.

We encourage you ALL to read the trials and decide for yourself - these are not individual reviews and merely summarise what the authors themselves have stated in their trial. The idea of infographics like this is, that via a quick read, you can identify some good #FOAMed articles that may peak your interest and you can explore them further. They also serve as good reminders to what goes on in a busy academic year.

Enjoy!

PDF FILES: (Please print out the document without alterations - keeping the websites etc on the page)

A joint collaboration from Dr. Jonny Wilkinson and Dr. David Lyness for International Fluid Academy.

Here we present Dr. Wilkinson & Dr Abdul Gomaa's excellent work on establishing a FLUID PROTOCOL for patients, establishing key processes within the prescription and considerations of IV fluids in the hospital.

Both of us are attending Internation Fluid Academy in Belgium this year (#IFAD2017) as Faculty. This is a high-end academic conference in Intensive Care Medicine that will have a heavy social media presence - focusing on fluid management, haemodynamics, POCUS and ICU management of the patient in fluid excess.

As with ALL FOAMed material, this protocol is for information only and we cannot take any responsibility for its use outside our spheres of practice. Nevertheless, it is enough to give you plenty of food for thought in creating your own flow-sheets in your own hospitals.

PS: The image is below, but you can see it in high definition and full-screen using this link here.

Quite obviously, similar to most spinal anaesthetic practices. This aims to provide a aide-memoire for out of hour (and in-hour!) practices where variability in all practitioners can exist. This is only ONE guide to providing a spinal anaesthetic and obviously is not made to replace AAGBI or OAA guidelines. It is something all staff can use to remind themselves of the equipment required and order things are done in. The BNF should always be used when prescribing medication and your patient may not be suitable for NSAID's or opioids OR stipulated antibiotic regimes due to contraindication or allergies. The post-operative analgesic regime is likely to vary a lot between hospitals depending on your local practices.

Furthermore, this does not replace the need for preparation for a general anaesthetic. You should always be mentally and procedurally prepared that the patient is going to have to emergently go to sleep for delivery.

The key aim of this document is to provide a snap-shot of information to aid staff help the anaesthetic team in siting a spinal in the safest, quickest way possible in a time-pressured situation. It can be used by everyone to raise the question of whether something on this list is needed, or has been purposefully omitted.

Anaesthetic assistants and midwifery staff should be sensitive to the needs to the anaesthetist and the procedure, as, the baby cannot come out via c-section until the spinal is in and working. With everyone working together, this can be achieved more quickly.

It allows the questions to be asked such as, "Do you want the oxytocin infusion prepared?" well before the baby comes out, because you have consulted the list of often-needed medications and it has reminded you. It also prompts early discussion with the obstetric team.

Perhaps it is not a useful infogram for seasoned practitioners, but it is certainly useful for the junior team seeking to be as thorough as possible.